PTSD Flashcards
Brief history of PTSD
- goes back a long way
- account of PTSD or similar sorts of symptoms have been documented for a very long time
- fills an important gap in psychiatry
- this is because its cause was the result of an event that the individual suffered / witnessed rather than a personal weakness
PTSD symptoms/conditions over time:
Soldiers Heart
- suggested that a physical injury was the cause of the symptoms
- marked by a rapid pulse, anxiety and trouble breathing
PTSD symptoms/conditions over time:
Da Costa’s Syndrome
- US doctor Jacob Mendez Da Costa
- studied civil war soldiers with ‘cardiac’ symptoms
- described it as overstimulation of the heart’s nervous system or Da Costa’s
- soldiers were often to returned to battle after receiving drugs to control symptoms
PTSD symptoms/conditions over time:
Railway Spine
- European reports of the symptoms
- rail travel became more common as did railway accidents
- autopsies of injured passengers
- suggested injury to the central nervous system
- symptoms associated with traumatic experiences - PTSD?
PTSD symptoms/conditions over time:
Shell Shock
- symptoms of present day PTSD - a reaction to the explosion of artillery shells?
- included panic, sleep problems etc
- first thought - the result of hidden damage to the brain caused by the impact of big guns
- very varied treatment during WW1 - few days of rest before returning to war
- Myers - looked at it as a disorder
- argued that it could be cured through cognitive & affective reintegration
- felt that he could help by reviving and integrating the individual’s memory within his consciousness
PTSD symptoms/conditions over time:
Combat Stress Reaction / Battle Fatigue
- replaced the shell shock diagnosis in WW2
- soldiers became battle weary and exhausted
- lots of officers in the military did not believe that the disorder was real
- lots of military discharges in WW2 were a result of combat exhaustion
PTSD symptoms/conditions over time:
Vietnam
- delayed stress
- turning point for PTSD
- bought it to the forefront of research
- lots of campaigning to bring the disorder into the public and medical eye
PTSD - military?
- not a disorder confined to the military
- BUT a lot of research has been done - due to the opportunities to study it maybe?
- Veterans associations have been pushing for getting research done
- military does fund a lot of research
PTSD - causes?
- caused by some sort of traumatic experience
- some occupations are likely to see more horrific scenes; police, rescue services, military personnel
- formerly thought of as an anxiety disorder that develops after experiencing or witnessing a life threatening event
- can be violent assault, accidents, war or sometimes severe emotional loss
- now in a new category - ‘Trauma and Stress Related Disorders’
PTSD - prevalence and co-morbidity?
High numbers in the US, bit less in the UK
- due to the motivations after Vietnam?
7.7% in USA (NIH, 2005)
3% in UK - Adult Psychiatric Morbidity Study
High co-morbidity with other disorders
- depression, anxiety, substance abuse
About 70% of those who suffer do not seek any help
DSM-V Criteria for PTSD
- Trauma or stressor - related disorder
- Numerous criteria
- Experience of the event
- Cues that make you remember
- Avoidance of anything associated with the event itself
- Negative change in mood and emotions
- Arousal and reactivity are affected
- Distortion of the event - self blame can result as well as detachment from life
- have to have been going on for a month!
NICE
National Institute of Health and Care Excellence
- provides national guidance and advice to improve health and social care
- doesn’t license drugs but does make recommendations
- based on the ICD-10
NICE symptoms for PTSD
> re-experiecneing symptoms - this can include flashbacks, nightmares, intrusions
> avoiding things that remind the person of the traumatic event - try to avoid think about or remembering the event
> hyper-arousal - hyper-vigilence, heightened startle response, sleep problems
> emotional numbing - difficulty with feelings, detachment
> mostly happens straight away but for some there is a delayed onset or the sufferers do not seek help until much later
> can be co-morbid - e.g. depression, anxiety disorders, substance abuse
Mnemonic - Lange, 2000
DREAMS
D - detachment
R - re-experiencing event
E - event had emotional events
A - avoidance
M - month in duration (symptoms more than one month)
S - sympathetic hyperactivity or hyper-vigilence
NICE - Assessment
- initial assessment and coordination of care - GPs
- includes determining the need for emergency medical or psychiatric assessment
- has to be comprehensive - physical, psychological, a social needs and a risk assessment
- P preference for treatment choice - important! - should be given sufficient information about the nature of treatments
- monitoring - needs to be clear agreement amongst health professionals about the responsibility for monitoring those with PTSD
- family support - play a central role in supporting P’s
- BUT depending on the nature of the trauma and consequences, many families may also need support for themselves (be aware of the impact all around!)
- self-help groups - should inform families and carers should be informed of these
Practical and social support can play an important part in facilitating a P’s recovery from PTSD, particularly immediately after the trauma
What can we use to diagnose PTSD?
Screening tools - only says it is likely that the disorder is present
Trauma / Symptom Severity - scales that might identify these include the Davidson Trauma Scale and DAPS (detailed assessment of post-traumatic stress)
Structured / Semi-structed interviews:
- CAPS - Clinician Administered PTD Scale
- CIDI - Composite International Diagnostic Interview
- DIS-1V - Diagnostic Interview Schedule for DSM 1V
–> for interviews, expertise is paramount!
CAPS - Clinician Administered PTD Scale
- gold standard in PTSD assessment
- 30 item structured interview
- can be used to make current diagnosis, lifetime diagnosis and assess symptoms over the past week
- some questions assess severity of the disorder
- can’t assess for co-morbidity though
CIDI - Composite International Diagnostic Interview
- comprehensive, fully-structured interview designed to be used by trained interviewers
- used for the assessment of mental disorders according to the definitions and criteria of ICD-10 and DSM-IV
- intended use - epidemiological and cross-cultural studies as well as clinical and research purposes
- lets the investigator measure the prevalence, severity and determine the burden, assess service use, use of medications in treatment, assess who is treated, untreated and barriers to treatment
- doesn’t require a trained clinician
- very specific
DIS-IV - Diagnostic Interview Schedule for DSM-IV
- fully structured questionnaire designed to ascertain the presence of absence of major psychiatric disorders outlined in the DSM-IV
- attempts to mimic a clinical interview by using questions to determine whether psychiatric symptoms endorsed by a respondent are clinically significant and are not explained by medical conditions or substance abuse
- has to be administered by trained interviewers
- used a lot in research
What are the different perspectives explaining PTSD?
Medical Model Dimensional Model Cognitive Model Behavioural Model Spiritual Model Narrative Model Systems Approach
Jakovlijević et al (2012)
Lots of different models / perspectives of PTSD
Psychotraumatisation - continues to be a pervasive aspect of life in the 21st century all over the world
PTSD and other trauma related disorders are highly prevalent and disabling as well as being a source of huge suffering
Multi-interpretable approach
- can be explained from various, but mutually complementary, theoretical and conceptual perspectives
- different internal logics but all plausible interpretations
Medical Model - disease/illness perspective
- Jakovlijević et al (2012)
Same as how somatic medicine works - something fundamentally different from normal function
- illness - damage to structure / function of the brain
- can be prevented or cured
- linking symptoms to specific patho-physiological processes involved and then prescribing specific treatments
> specific structural and functional changes have been reported in the brains of P’s with PTSD
Medical Model - in terms of psychodynamic psychiatry
- Jakovlijević et al (2012)
Illness is subjective and is an interpersonal manifestation, to do with meaning
- problem of the whole person therefore is subjectively defined
- reflects the malfunction of a harm avoidance mechanism
- normally use past experiences to escape actual or future dangers, hazards and damage
Treatment - attention to the WHOLE person
- assumption that disease captures the essence of illness if erroneous
- in clinical practise, PTSD modifies both as illness and disease!
Medical Model - in terms of social psychiatry
Jakovlijević et al (2012)
PTSD - a sickness that represents community and health authority attitude
- influence of society - shape how P’s feel about the disorder
- political valence - influences the construct of the disorder and the response to P’s with the disorder
Jakovlijević et al (2012) - an explanation in terms of medical factors?
Traumatic situations - neurons can literally be ‘excited to death’ - this results in organic brain changes
Fundamental problem in PTSD - a fixation on trauma and damage of the self-regulatory systems which are unable to distinguish relevant from irrelevant stimuli and to restore to the organism to its pre-trauma state
